This statement may seem unusual for a hospital—after all, we want patients in the hospital, don’t we?

Well, not when they’ve been our patient in the last 30 days. Readmissions cost Medicare $1.7 billion annually, and the Preventable Readmissions Program (part of the Affordable Care Act) will begin to financially penalize hospitals determined to have an excess of readmissions, beginning this year.

CCMH now has an innovative way to address readmissions to the hospital, a grant program called the Wyoming Rural Care Transition Program. It’s a statewide program designed to improve quality, reduce readmission and contain costs for patients who are 65 and older with at least one of ten qualifying diagnoses. This program enabled CCMH to hire a Care Transition Coach, Angela Roesler, RN, to educate and empower patients during and after their hospital stay. Angela was a nurse on Med Surg prior to her new position, and already knew and loved this patient population from her work on the nursing unit.

“I love my new job so far,” said Angela. “The patients and their families are very receptive, especially the caretakers at home that don’t have a medical background.”

Angela sees all the eligible inpatients and asks if they want to participate in the program, which is free to the patient. They are eligible if they meet the age criteria of 65, and have at least one of these diagnoses (even if their hospitalization was not caused by that diagnosis): congestive heart failure, chronic obstructive pulmonary disease, coronary artery disease, diabetes, stroke, medical/surgical back disorder, hip fracture, peripheral vascular disease or pulmonary embolism.

She follows them after discharge for up to 90 days with phone calls and home visits. Research shows 40-50 percent of readmissions are due to a lack of support, and 50 percent of patients don’t follow up with their primary care provider within 30 days of discharge from the hospital.

“The key is to find out what needs to change at discharge for them to stay out of the hospital,” said Angela. “I get the feel of what they know about their diagnosis, and help them learn about their disease and their limitations.”

She works with any home health providers, even meeting them in the patient’s home. Angela doesn’t provide nursing care in her role, but can provide information to home care providers about the patient to improve the continuity of care.

Angela has seen 19 patients since she started May 13. While it’s too soon to tell how this new role will effect readmissions at CCMH, the program’s goal is to reduce readmissions by 20 percent for the eligible population. Cheyenne saw a 50 percent decrease in readmissions in the first quarter after they implemented the program.

She spends most of her time either on the nursing unit or in the patient’s home. A laptop and software, to be provided by the grant program, will help with the extensive documentation required.

“I had a CHF (Congestive Heart Failure) patient who had been diagnosed for years,” said Angela. “She and her family didn’t know the basics to look for to tell if her illness was getting worse.”

Call Angela at 307.688.1371 for information about the Rural Care Transition Program. Her office is located in the Quality department in the Administrative suite on the ground floor of the expansion.